[104-10222-10012.pdf — page 280]
# "EALTH BENEFITS REGISTRATION FOR A 3400FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959Standard Form No. 2809CHAPTER 1-3 P.M(Read back of last page. Use only in then ink)1. NAME (LAST)RANDALL4. YOUR MAILING ADDRESS (NUMBER AND STREET)4225 Door Drive(FIRST) (MIDDLE INITIAL)Frederick C.(CITY AND ZONE NUMBER) (STATE)McLean, Virginia6. Are you covered by, or in any family member listed below covered by, or enrolling in, a plan under the Federal Employees Health Benefits Act of 1959 (through the enrollment of another United States or District of Columbia Government employee or annuitant)?YES  NOCARRIER'S CONTROL NO.0944323. Are you now married?YES  NOMALEFEMALE7. Place an "X" in proper box to show your annual basic salary rangeUNDER $4,000  $6,000 TO $7,999$4,000 TO $5,999  $10,000 OR OVER1. I elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity to cover my share of the cost of the enrollment. (Copy the information requested below from inside cover of brochure of the plan you select.)NAME OF PLANASSOCIATION BENEFIT PLANOPTION (HIGH OR LOW)HIGHENROLLMENT CODE NUMBER4 2 22. In space below list all eligible family members without exceptions: list your wife or husband first, then your unmarried children under age 19, including legally adopted children, and stepchildren and illegitimate children who live with you in a regular parent-child relationship. Include also any unmarried child over age 19 who became disabled before age 18 and who, because of the disability, is incapable of self-support. (Attach a doctor's certificate for a disabled child age 19 or over.)| NAMES OF FAMILY MEMBERS            | DATE OF BIRTH (Month, day, year) | NAMES OF FAMILY MEMBERS | DATE OF BIRTH (Month, day, year) || ---------------------------------- | -------------------------------- | ----------------------- | -------------------------------- || Wife or Husband: Irma Jean Rendall | Nov 20, 26 [^1]                  |                         |                                  || Kirk Frederick Randall             | June 19, 51 [^2]                 |                         |                                  || Thomas 7. Randall                  | Dec 2, 52 [^3]                   |                         |                                  || Joan Ellen Randall                 | Oct 4, 56 [^4]                   |                         |                                  || Barbara Jean Randall               | Nov 25, 58 [^5]                  |                         |                                  |3. If you are a female (employee or annuitant)-does the family listed above include a husband who is incapable of self-support by reason of mental or physical disability which can be expected to continue for more than one year? (If answer "Yes," attach a doctor's certificate.)YES  NOPLACE AN "X" IN ITEM 1. OR ITEM 3. WHICHEVER APPLIES AND ANSWER ITEM 31. I elect not to enroll in any plan under the Health Benefits Act.3. The reason for my election is (Place an "X" in proper box):(a) I am covered by a plan under the Health Benefits Act through the enrollment of my husband, wife, or parent.2. I elect to cancel my present enrollment under the Health Benefits Act(b) I am covered by a health insurance plan which is not under the Health Benefits Act.(c) Any other reasonI elect to change my enrollment as shown below by:1. Enrollment code number of present plan. 2. Number of event which permits change. 3. Date of event which permits change.   (See table in back of duplicate for proper number.)   MONTH DAY YEARWARNING.-Any intentional false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)1. DATE RECEIVED IN PERSONNEL OFFICE 3. EFFECTIVE DATE OF ELECTION   5-20-60 1-10-604. PERSONNEL OFFICE NO. 5. PAYROLL ACTION (INITIALS AND DATE)REMARKSFOR USE ONLY BY ANNUI- TANTS AND AGENCY.FEEmployee-to-Employing Office112170[^1]: [^2]:[^3]: [^4]:[^5]: